4. Developing a standardised process for managing ED
capacity

Crowding affects various parts of the hospital in different but
interrelated ways. Locally agreed definitions of crowding must be
developed and must be clear, specific and detailed about when
triggers are activated.

Developing a standardised process for managing
ED capacity will
help to reduce variation and embed a culture of early referral and
proactive capacity management, ensuring that patient flow is
high-quality, safe and effective.

There should be agreed standard actions during the daytime and a
clear plan in place for escalation out of hours. Senior staff in
the hospital overnight should have the ability and authority to
action these plans.

Thresholds for capacity stress should be agreed and defined
locally. They must take into account incremental delays to moving
patients from the
ED or assessment
areas, together with escalating markers of crowding.

Monitoring and managing every patient journey may require a
tracking system. Escalation at specific points, such as first
assessment, diagnostics and treatment, should be considered;
escalation should be clearly defined at an early stage in the
patient's journey to prevent crowding.

A standardised process should consider the following key
components:

Clear and visible department management Leadership and management of the
ED and assessment
areas ensures a focus on every patient, every time and monitors
steps in the patient's journey to minimise delays. Some departments
have used the role of flow coordinator as an alternative to robust
electronic systems to good effect. Both approaches monitor patient
care pathways and inform escalation processes where necessary.

A monitoring tool may need to be developed locally for each
agreed journey point.

Decision to admit Patient journeys cannot be delayed in the
ED by waiting for
specialist review or requests for tests that are not going to
influence the decision to admit. Tests or investigations in the
ED should
nevertheless be prioritised to reduce delay in disposition
decisions.
4 A key role of the
ED is to identify
patients who do not require in-patient care and to discharge them
safely with appropriate follow up.

The decision to admit a patient should rest with a senior
emergency medicine clinician at level
ST4 (specialty
training year 4) or above who has the necessary knowledge to assess
risk in undifferentiated patients presenting to
EDs. This is
clearly dependent on staffing levels locally and may not be
feasible 24 hours a day on all sites. When a senior emergency
medicine clinician is available, there should be an expectation
that he or she reviews all referrals for admission.

Once the decision to admit is taken, the patient should be moved
to the ward when clinically appropriate without further delays for
secondary review. The same should be true of patients in other
direct-access receiving units (such as acute medical units) who
have been reviewed by the admitting consultant and deemed
appropriate for transfer (and take-over of care) to a downstream
ward. This might involve the use of locally agreed, clinically
relevant admission, transfer and discharge criteria to reduce
variation.

Early notification Sites should ensure they have robust systems in place to
monitor and manage capacity proactively on a daily basis. With
improved communication of capacity and demand, early notification
has been seen to be an effective early escalation step

and will alert clinical teams to capacity and demand alignment
issues earlier in the day. While the focus of all early assessment
should be the conversion of unscheduled to scheduled care and
admission avoidance, nonetheless in a proportion of cases it will
be evident from very early in the process that admission is
inevitable.

The receiving ward should be notified and a predetermined
process followed if it is expected from initial triage or first
assessment that a patient will require admission. It is accepted
that some of these referrals may later be cancelled: the proportion
of such cancellations should be reviewed as part of process
evaluation.

As an example, a triage nurse may refer from the
ED and be presented
with three responses from the admitting ward:

a bed is available and is now allocated to your patient -
transfer when ready

a bed will be available within an hour - transfer at or after
this time

no bed is available and it is unlikely that one will be
available in an hour - this issue will be escalated.

A policy to describe how this information informs the escalation
process should be in place. The key element is that a standard
operating procedure should monitor each patient's journey every day
to review capacity, and the system should respond at an early stage
of delay to prevent crowding.

A mutually agreed pathway of care should be implemented for "to
be admitted" patients (including those referred by a
GP). Investigations
in the
ED should be
limited to those required for emergency management or those that
would immediately influence management on the patient's arrival in
an acute admission unit.

Pull policy

A pull policy describes a process by which specialist clinical
areas try to match their capacity to a predicted demand as early in
the day as possible as part of a standard operating procedure.

Understanding the expected specialty demand and therefore how
much capacity is needed will allow specialties to plan and design
pathways for optimal care, and at an individual ward level, would
enable medical and surgical pathways to ensure the maximum number
of patients are cared for by the most appropriate clinical team at
the earliest opportunity in the assessment process.

Once these pathways are in place a process to support movement
of patients to the appropriate specialty avoiding unnecessary waits
and delays would be established. The particular specialty would
identify appropriate patients and operate a pull policy from
ED or acute
assessment matched to their capacity and demand profile described
above.

For the pull policy to be effective, individual clinical areas
must ensure adequate capacity is achieved as early in the day as
possible. This requires
NHS Boards to
ensure their local site
6EA improvement
plans include work on developing Basic Building Blocks to determine
demand and proactive discharge processes such as effective use of
Daily Dynamic Discharge measures including; Estimated Dates of
Discharge; multi-disciplinary whiteboard meetings, daily ward round
and utilization of criteria led discharge to increase morning and
weekend discharges, and use of discharge lounges to facilitate this
process.

On occasion a pull policy may be included within an escalation
approach where specialty consultants are instrumental in pulling
patients from
ED and /or
assessment areas to specialty beds in a more timely manner.

Push Policy This describes the transfer of a patient from a receiving
area to a continuing care area where a patient has been identified
for discharge but the bed is not currently ready or still occupied.
For example, when a patient will be discharged that day but it is
not appropriate to wait in the discharge lounge. In these
circumstances the patient arriving on the ward will require to be
managed outwith a bed space for a period of time. This would
reflect serious stress in the system and would require close
cooperation between senior clinical teams in the admitting and
continuing care areas with careful balancing of the relative risk.
Where proactive daily dynamic discharge approaches and pull
policies are routinely enacted, core to daily capacity planning,
the requirement for push policies to be activated will be
minimised.

The requirement to use "push" policies where crowded
ED and Assessment
Units move patients to in-patient areas in advance of planned
confirmed discharges should be seen as a sign of capacity stress.
Patients 'pushed' to downstream wards from assessment units should
have had a locally agreed level of work up, which is likely to
include a consultant decision that the patient is ready to move.
Local arrangements should be in place to determine safe and
acceptable time limits, within which a bed is expected to become
available.

This should however be distinguished from a "Full Capacity
Protocol" where A&E or Assessment Unit patients are moved to
in-patient units as "extra patients" in response to a particularly
severe risk through crowding. The requirement to activate a Full
Capacity Protocol should be considered a critical incident
requiring a response to untoward and unexpected circumstances with
a similar threshold to declaring a major incident.

It is essential that proactive actions are in place across
the system to ensure crowding does not occur.

Escalation steps to eliminate crowdingNHS boards
should develop their standardised processes for managing
ED capacity in the
context of this guidance and the 6 Essential Actions to Improving
Unscheduled Care. The steps should ensure that patient flow is
effective, safe and high quality, thereby proactively avoiding
crowding and its negative implications for patient care.

Escalation steps must be agreed across executive, management and
clinical levels to ensure agreed standard actions are in place in
the event of crowding. They should cover daytime hours, with a
clear plan for escalation out of hours. Senior staff in the
hospital overnight should have the ability and authority to action
these plans.

Based on the agreed standard operating procedure, thresholds for
capacity stress and crowding should be defined locally: the agreed
limits should be reached before escalation steps are activated.

The advised escalation steps take into account incremental
delays to moving patients from
ED or assessment
areas and escalating markers of crowding. Three distinct stages
must be clearly identified in the plan. The following steps should
be considered the minimum standards for escalation.

1. Clinically appropriate beds are not available for a
predetermined number of patients defined locally (this is likely to
be 10 to 30 per cent of a, fully occupied
ED/Assessment
Area/trolley spaces) within
two hours4 of the senior clinician's decision that the patient is ready
to move. The following actions should be considered by senior
operations managers at this time:

alert senior clinicians and managers across affected teams
and convene in the
ED or assessment
area affected by crowding

initiate proactive discharges across all wards and
departments including check, chase, challenge to identify all
additional discharges

open additional acute staffed beds

review non-urgent elective care such as operations, infusions
or investigations, and consider deferral.

implement a 'sit out' process as part of a pull policy where
the bed is made available before the previous patient has left
the hospital

2. Clinically appropriate beds are not available for a
predetermined number of patients defined locally (likely to be 10
to 30 per cent of a fully occupied
ED/Assessment
Area/trolley spaces) within
four hours of the senior clinician's decision that
the patient is ready to move,
or the
ED is operating at
more than 100 per cent capacity,
or ambulances are unable to unload for more than
30 minutes due to lack of appropriate space. The senior operations
manager continues with actions in Step 1. The medical director and
senior management team should consider immediately:

cancelling all non-critical surgery across all specialties to
free beds for admission and boarding

3. If clinically appropriate beds are not available for a
predetermined number of patients defined locally (likely to be 10
to 30 per cent of fully occupied
ED/Assessment
Area/trolley spaces) within
eight hours of the decision by senior clinicians
that a patient is ready to move,
or the
ED is operating at
more than 100 per cent capacity (that is, using non-clinical
space), the following actions are required:

immediate notification to the chief executive

emergency incident group convened (to include senior
clinicians from acute and in-patient specialties, emergency
medicine and social work).

The emergency incident group should consider the following
responses to ensure the rapid protection of patients from further
harm:

activation of a locally agreed full-capacity protocol(a
patient being transferred to a ward or unit without a bed being
available) to transfer safely acute workload to in-patient areas
to avoid critical overload of the
ED or assessment
areas

closure of the
ED to new
patients and diversion to neighbouring hospitals where possible
(including discussion with neighbouring boards and the Scottish
Ambulance Service).

Note The group does not endorse these approaches
as part of normal management. The implementation of either of the
last two actions detailed in bullet 3 above should be considered an
exceptional response to untoward and unexpected circumstances and
must be authorised by the Chief Executive/Medical Director or
formal deputy at the request of the triumvirate leadership team. A
Level 5 serious incident review will be necessary. Scottish
Government Performance Management must be informed and the board
and government press offices notified.

It is essential that all steps are taken to develop a standard
operating procedure that monitors each patient to ensure crowding
is avoided. All steps should be taken to understand
decision-to-admit processes, capacity planning and early
notification requirements.

Use of escalation step 3 indicates the standard operating
process is flawed and repeated use suggests a failing system.